Healthcare Provider Details

I. General information

NPI: 1467762500
Provider Name (Legal Business Name): CARLENE ADELE MOORE R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2010
Last Update Date: 10/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14706 JUILLIARD COURT
MAGALIA CA
95954
US

IV. Provider business mailing address

P.O. BOX 1143
PARADISE CA
95967-1143
US

V. Phone/Fax

Practice location:
  • Phone: 530-873-0830
  • Fax:
Mailing address:
  • Phone: 530-873-0830
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number251108
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: